Pediatric asthma treatment: What to do when international guideline recommendations do not agree.

BACKGROUND: There was a need for a solid asthma guideline in Mexico to update and unify asthma management. Because high-quality asthma guidelines exist worldwide, in which the latest evidence on asthma management is summarized, the ADAPTE approach allows for the development of a national asthma guideline based on evidence from already existing guidelines, adapted to national needs. OBJECTIVE: To fuse evidence from the best asthma guidelines and adapt it to local needs with the ADAPTE approach. METHODS: The Appraisal of Guidelines for Research and Evaluation (AGREE) II asthma guidelines were evaluated by a core group to select 3 primary guidelines. For each step of asthma management, clinical questions were formulated and replied according to (1) evidence in the primary guidelines, (2) safety, (3) Cost, and (4) patient preference. The Guidelines Development Group, composed of a broad range of experts from medical specialties, primary care physicians, and methodologists, adjusted the draft questions and replies in several rounds of a Delphi process and 3 face-to-face meetings, taking into account the reality of the situation in Mexico. We present the results of the pediatric asthma treatment part. RESULTS: Selected primary guidelines are from the British Thoracic Society and Scottish Intercollegiate Guidelines Network (BTS/SIGN), Global Initiative for Asthma (GINA), and Spanish Guidelines on the Management of Asthma (GEMA) 2015, with 2016 updates. Recommendations or suggestions were made for asthma treatment in Mexico. In this article, the detailed analysis of the evidence present in the BTS/SIGN, GINA, and GEMA sections on the (non) pharmacologic treatment of pediatric asthma, education, and devices are presented for 2 age groups: children 5 years or younger and children 6 to 11 years old with asthma. CONCLUSION: For the pediatric treatment and patient education sections, applying the AGREE II and Delphi methods is useful to develop a scientifically sustained document, adjusted to the Mexican situation, as is the Mexican Guideline on Asthma.

[Mexican Asthma Guidelines: GUIMA 2017]. / Guía Mexicana del Asma: GUIMA 2017.

BACKGROUND: The need for a national guideline, with a broad basis among specialists and primary care physicians was felt in Mexico, to try unifying asthma management. As several high-quality asthma guidelines exist worldwide, it was decided to select the best three for transculturation. METHODS: Following the internationally recommended methodology for guideline transculturation, ADAPTE, a literature search for asthma guidelines, published 1-1-2007 through 31-12-2015 was conducted. AGREE-II evaluations yielded 3/40 most suitable for transculturation. Their compound evidence was fused with local reality, patient preference, cost and safety considerations to draft the guideline document. Subsequently, this was adjusted by physicians from 12 national medical societies in several rounds of a Delphi process and 3 face-to-face meetings to reach the final version. RESULTS: Evidence was fused from British Thoracic Society Asthma Guideline 2014, Global Initiative on Asthma 2015, and Guía Española del Manejo del Asma 2015 (2016 updates included). After 3 Delphi-rounds we developed an evidence-based document taking into account patient characteristics, including age, treatment costs and safety and best locally available medication. CONCLUSIONS: In cooperation pulmonologists, allergists, ENT physicians, paediatricians and GPs were able to develop an evidence-based document for the prevention, diagnosis and treatment of asthma and its exacerbations in Mexico.

Antecedentes: Con el objetivo de unificar el manejo del asma en México se estructuró una guía clínica que conjunta el conocimiento de diversas especialidades y la atención en el primer nivel de contacto. Se seleccionaron 3 guías publicadas en el ámbito internacional para su transculturación. Métodos: Conforme a la metodología ADAPTE se usó AGREE II después de la búsqueda bibliográfica de guías sobre asma publicadas entre 2007 y 2015. Se fusionó la realidad local con la evidencia de 3/40 mejores guías. El documento inicial fue sometido a la revisión de representantes de 12 sociedades médicas en varias rondas Delphi hasta llegar a la versión final. Resultados: Las guías base fueron la British Thoracic Society Asthma Guideline 2014, la Global Initiative on Asthma 2015 y la Guía Española del Manejo del Asma 2015. Después de 3 rondas Delphi se desarrolló un documento en el que se consideraron las características de los pacientes según edad, costos de los tratamientos y perfiles de seguridad de los fármacos disponibles en México. Conclusión: Con la cooperación de neumólogos, alergólogos, otorrinolaringólogos, pediatras y médicos generales se llegó a un consenso basado en evidencia, en el que se incluyeron recomendaciones sobre prevención, diagnóstico y tratamiento del asma y sus crisis.

Teorías para la paz y perspectivas ambientales del desarrollo como diálogos de imperfectos / Theores for peacce and development environmental perspectives as imperfect dialogues

Desde finales de la segunda guerra mundial, en distintos centros e institutos de Investigación, se están desarrollando teorías sobre y para la paz (quizá sea más adecuado referirse a las paces, dada la inobjetable polisemia del concepto) que la vinculan a la cesación de las violencias o, de manera más amplia, a la solución pacífica de los conflictos. Una de los desarrollos más recientes es la Paz Imperfecta, a través de ella es posible detectar acciones que crean paz a pesar de estar en contextos de alta conflictividad y violencia. En esta línea de análisis la paz como ideal absoluto y perpetuo es sustituida por una gama amplia y variopinta de paces posibles, abriendo, de esta manera, un espacio sugerente para examinar las probables conexiones entre los pensamientos y acciones de pacifistas y ambientalistas, teniendo como fondo un juicio crítico común al modelo de desarrollo imperante. El presente texto hace un recorrido teórico por algunas de las reflexiones más estimulantes sobre la paz; en la ruta, el documento construye conexiones entre una de estas perspectivas (paz imperfecta) y algunas de las variantes del pensamiento ambiental; como se sabe, estas últimas han dado paso a múltiples visiones del desarrollo alternativo, buena parte de ellas centradas en la búsqueda de la sustentabilidad.

Since the end of the Second World War, theories about and for peace (probably it would be more adequate to refer to them as peaces because of the unobjectionable polysemy of this concept) which link it to the ceasing of violence or, in a wider sense, to pacific problem solving, have been developed. One of the most recent developments is the so called Imperfect Peace, through which it is possible to detect actions that generate peace in spite of being in high conflictive and violent contexts. In this line of analysis, peace as an absolute and perpetual ideal is substituted by a wide and varied spectrum of possible peaces, opening in this way suggestive space to examine the possible connection between pacifists and environmentalists’ thoughts and actions, having as a background a critical judgment common to the prevailing development model. This article makes a theoretical scan on some of the most stimulant reflections about peace; on the road the document builds connections between one of these perspectives (Imperfect Peace) and some of the environmental thought variables; as it is well known these last ones have given way to multiple visions of alternative development, many of then focused on the search for sustainability.

La política pública para la atención al desplazamiento forzado en el departamento de caldas y en los municipios de Riosucio y Samaná (1997-2006) / Public policy frr the attention of victims of forced displacement in the department of caldas in the municipalities of riosucio and samana (1997-206))

A pesar de la magnitud del drama humanitario generado por el desplazamiento forzado en Colombia -y no obstante de la creación de un amplio marco jurídico para la atención a las personas en condición de desplazamiento-, la acción institucional se ha centrado en la atención humanitaria de emergencia; esta es una conclusión común en los balances nacionales acerca del cumplimiento de la política pública para la atención a la población en situación de desplazamiento. Si bien se cuenta con buen número y alta calidad en las evaluaciones y balances nacionales de la política, es muy poco lo que se ha investigado acerca de la puesta en marcha de las políticas públicas en el Departamento de Caldas. A diferencia de las evaluaciones realizadas hasta ahora, la que se presenta en este trabajo no está orientada a cuantificar recursos destinados para la atención, busca más bien examinar la forma como se ha interpretado el problema por parte de los decisores públicos, la manera como se ha planificado la respuesta estatal y la forma como se ha propiciado o no la participación de la población afectada. A este tipo de aproximación se le puede definir como evaluación política de la política pública, para el período 1997-2006.

In spite of the magnitude of the humanitarian drama generated by the forced displacement in Colombia, and even though an inclusive legal framework has been created for the attention of displaced persons, the institutional actions have been focused on emergency humanitarian attention. This is a common conclusion in the national balances on the fulfillment of the public policy regarding the attention to displaced persons. Although the national evaluations and balances regarding the policy are numerous and of high quality, the research on the use of these public policies in the department of Caldas has been scarce. Differing from the evaluations carried out up to the present, the one presented in this article is not oriented towards the calculation of the resources destined for said attention; instead, it seeks to examine the manner in which the state response has been planned and the way in which the participation of the target population has been promoted. This kind of approach can be defined as a political evaluation of the public policy for the 1997-2006 period.

Experiencias de paz en conflictos fronterizos por el agua / Peace xperiencess in border conflicts due t water

El artículo aborda algunos de los conflictos recientes surgidos entre países por la disputa de los recursos hídricos compartidos, en especial por los ríos fronterizos. A pesar de las complejas problemáticas entre países fronterizos que, en algunos casos, convocan múltiples formas de violencia como camino para tramitar las diferencias de intereses, en la realidad emergen diversas experiencias de paz que permiten generar y mantener acuerdos sobre el uso y el acceso al agua. Estas experiencias de paz pueden señalarse como formas de paz imperfecta. En la primera parte del artículo se presenta un marco general de los conflictos recientes entre países como producto de diversos intereses frente al tema del agua; en la segunda parte se realiza una revisión de la problemática ambiental en el marco de los estudios actuales sobre la paz; por último, se presentan experiencias de paz entre los países que disputan recursos hídricos, reportadas por organismos de las Naciones Unidas y ordenadas con base en la matriz propuesta por el profesor Francisco Muñoz de la Universidad de Granada.

This document describes some international conflicts that are a consequence of the fight for shared hydrological resources, especially rivers located at international borders. It is a paradox that, despite the complex problems between bordering countries that negotiate through violence in conflicts of interests, many peace experiences emerge in reality in order to generate and maintain agreements concerning the use and access to water. These peace experiences can be called "imperfect peace experiences". The first part of the text presents a general context of recent international conflicts as a result of different interests regarding water-related topics. Secondly, a review of the environmental problems within the framework of current studies concerning peace is carried out. Finally, some of the peace experiences between countries in dispute over hydrological resources are introduced, reported by different organizations belonging to the United Nations, and are then ordered according to the model proposed by Francisco Muñoz, professor of the Universidad de Granada.

[Epidemiology of asthma]. / Epidemiología del asma.

Through the use of the same questionnaire translated to several Languages, the ISAAC study demonstrated that asthma prevalence among children and adolescents greatly vary around the world, being less than 2% in some places and more than 25% in others. In Mexico the prevalence is also variable, being for example approximately 5% in Mexico City and approximately 12% in Merida, Yucatán. This variability in the asthma frequency correlates inversely with the altitude of the region and directly with its temperature. According to official statistics, the nationwide annual incidence of asthma in Mexico is 2.78 per 1000 inhabitants. In last decades an epidemic rise of asthma cases was recorded in many parts of the world, which seems to become stabilized from the middle of 90's onward. Asthma frequency augments in some months of the year, being in Mexico much higher between October and January. The peak incidence of asthma occurs among children, diminishes in adolescence and early adulthood, and slightly rises in subsequent age-periods. During childhood, asthma frequency is higher in males, but after adolescence becomes more common among women. In Mexico, asthma mortality has been gradually declining since more than 15 years ago.

[Physiopathology of asthma]. / Fisiopatología del asma.

The most distinctive functional abnormality in asthma is increased airway resistance (Raw), especially in those airways located peripherically (< 2 mm diameter). Smooth muscle contraction, mucous hypersecretion and swelling of the airway wall due to inflammation and/or remodeling are major factors originating airway lumen diminution. However, two other factors also favoring airway closure in asthma are surfactant alterations produced by the inflammatory process and decrement of transpulmonary pressure (PL), also known as elastic recoil pressure. In normal conditions, at the end of a passive expiration there is equilibrium between the lung tendency to collapse and of the chest wall tendency to expansion. During an asthma exacerbation lungs loss elasticity, i.e., the already decreased PL is accentuated, making that equilibrium between lungs and chest wall is achieved at higher volumes (increment of functional residual capacity [FRC]), which implies that the patient breaths maybe the same tidal volume but with more inflated lungs. During a forceful expiration the premature airway closure originates air trapping (increased residual volume). If asthma exacerbation is severe enough, abnormal regional ventilation might be in disequilibrium with respect to blood perfusion and cause hypoxemia, and the enhanced respiratory work load might lead to respiratory muscle fatigue, hypoventilation and hypercapnia.

Evaluación nutricional en lactantes hospitalizados / Nutritional evaluation of hospitalized infants

Se estudiaron todos los lactantes entre 1 y 24 meses de edad hospitalizados por más de 10 días entre Julio 1983 y Enero 1984 en el hospital Sótero del Rio. Los pacientes fueron controlados semanalmente hasta el mes de estada, mediante peso, talla, perímetro braquial (PB), pliegue tricipital (PTr), albuminemia y Hb. La hospitalización fue más prolongada cuando P/E o P/T < ou = 90% al ingreso que en eutróficos (18+ou- vs 31 + ou - 28 días, p<0.05); la diarrea fue más frecuente como causa de hospitalización en los pacientes con P/E < ou = El PB < percentil 5 fue más frecuente en los lactantes que tuvieron hospitalizaciones más prolongadas y se relacionó bien con P/E < ou = 80%; el PTr < p5, no mostró mayores variaciones en los controles semanales. Se encontró baja prevalencia en hipoalbumenemia en controles iniciales (< 16%); y la proporción de pacientes con concentraciones deficientes de hemoglobina se mantuvo elevada entre los hospitalizados por tiempos prolongados (> 70%)

Compromiso cerebeloso en fiebre tifoídea / Cerebelar involvement in typhoid fever

Una niña de 8 años presentó síntomas de compromiso cerebeloso al término de la primera semana de evolución de una fiebre tifoídea demostrada con hemocultivos ymielocultivos. Los exámenes y el cultivo de líquido cefalorraquídeo dieron resultados normales. Los síntomas y signos desaparecieron después de iniciar el tratamiento con Cloramfenicol y estaban ausentes quince días después del alta